A Comparative Study of the Amount of Bleeding and Hemodynamic Changes between Dexmedetomidine Infusion and Remifentanil Infusion for Controlled Hypotensive Anesthesia in Lumbar Discopathy Surgery: A Double-Blind, Randomized, Clinical Trial

Dexmedetomidine versus remifentanil for controlled hypotension under general anesthesia: A systematic review and meta-analysis

This meta-analysis aimed to analyze and compare the efficacy and safety of remifentanil and dexmedetomidine applied respectively for controlled hypotension under general anesthesia. We searched the Cochrane Library, PubMed, EMBASE, Web of Science, CNKI, SinoMed, Wanfang, and VIP databases, as well as dissertations and conference papers, to obtain randomized controlled trials comparing remifentanil and dexmedetomidine applied respectively for controlled hypotension before August 23, 2021. The primary outcomes included hemodynamic profiles, surgical field score, and blood loss. Extubation time, sedation and pain score at the PACU, and perioperative adverse events were the secondary outcomes. Nine randomized controlled trials with 543 patients (272 in the dexmedetomidine group and 271 in the remifentanil group) were eventually included. This meta-analysis indicated no significant difference between dexmedetomidine and remifentanil in terms of surgical field score, blood loss, minimum values of mean arterial pressure (MD 0.24 with 95% CI [-1.65, 2.13], P = 0.80, I2 = 66%) and heart rate (MD 0.42 [-1.33, 2.17], P = 0.64, I2 = 40%), sedation scores at the PACU (MD -0.09 [-0.69, 0.50], P = 0.76, I2 = 92%), and incidence of bradycardia (OR 2.24 [0.70, 7.15], P = 0.17, I2 = 0%). Compared with remifentanil, dexmedetomidine as the controlled hypotensive agent showed a lower visual analogue score at the PACU (MD -1.01 [-1.25, -0.77], P<0.00001, I2 = 0%) and incidence of shivering (OR 0.22 [0.08, 0.60], P = 0.003, I2 = 0%), nausea, and vomiting (OR 0.34 [0.13, 0.89], P = 0.03, I2 = 0%). However, extubation time was shorter in the remifentanil group (MD 3.34 [0.75, 5.93], P = 0.01, I2 = 90%). In conclusion, dexmedetomidine and remifentanil are both effective in providing satisfactory controlled hypotension and surgical conditions. Dexmedetomidine is better in easing postoperative pain at the PACU and reducing the occurrence of shivering, nausea, and vomiting. Meanwhile, remifentanil is a fast-track anesthesia with a shorter extubation time. Given the limitations of this meta-analysis, further studies are needed for a more definitive comparison of the efficacy and safety of dexmedetomidine and remifentanil.

Effects of the Two Doses of Dexmedetomidine on Sedation, Agitation, and Bleeding During Pediatric Adenotonsillectomy

Background

Due to the importance of dexmedetomidine and its different dosages, here, we aimed to investigate and compare the effectiveness of the doses of 1 µg/kg and 2 µg/kg of dexmedetomidine in sedation, agitation, and bleeding in pediatrics undergoing adenotonsillectomy.

Methods

This double-blinded randomized clinical trial was performed on 105 pediatric patients that were candidates for adenotonsillectomy. Then, the patients were divided into three groups receiving dexmedetomidine at a dose of 2 µg/kg, diluted dexmedetomidine at 1 µg/kg, and normal saline. The drugs were administered 15 minutes before operations via the intravenous method. The duration of extubation, mean arterial pressure (MAP), heart rate (HR), and SPO₂ in the recovery were recorded. We also collected data regarding patients’ sedation and agitation every 15 minutes.

Results

Our data showed no significant differences between the groups of patients regarding MAP, HR, and SPO₂. However, the mean sedation score was significantly higher in patients receiving dexmedetomidine (2 µg/kg), and this score was lowest in the control group at the time of entrance to the recovery room. The patients that received dexmedetomidine at a dose of 1 µg/kg had the lowest agitation score after 45 minutes of being in the recovery room, and the patients treated with dexmedetomidine at a dose of 2 µg/kg had the lowest agitation score after 60 minutes of being in the recovery compared to other groups of patients.

Conclusions

The use of the doses of 1 µg/kg and 2 µg/kg of dexmedetomidine was associated with proper sedation and a significant reduction in agitation. The patients also had lower amounts of bleeding. We recommend that anesthesiologists should pay more attention to dexmedetomidine at a dose of 2 µg/kg, especially in pediatric surgical procedures.

Comparison of the Effect of Two Different Doses of Labetalol to Induce Controlled Hypotension on Hemodynamic Changes During Spinal Fusion Surgery

Background: Spinal fusion surgery is often associated with heavy bleeding. Labetalol is one of the most effective drugs used to control bleeding in surgery. Objectives: Here, we measured the effect of two therapeutic doses of labetalol on the amount of bleeding. Methods: This is a randomized clinical trial that was performed in 2020-2021 in Al-Zahra hospital in Isfahan, Iran, on patients that were candidates for posterior spinal fusion surgery under general anesthesia. A total number of 64 patients were entered and randomized into two groups, one receiving labetalol at the dose of 2 mg/min and another group at 4 mg/min during surgery. The amount of bleeding in patients, heart rate, blood pressure, blood oxygen saturation, hypotension or bradycardia, and the mean length of stay in the recovery room were measured and compared between the groups. Results: Extubation time (14 ± 4) and recovery time (76 ± 17) were significantly lower in patients that received labetalol (2 mg/min) compared to another group (21 ± 7 for intubation time and 116 ± 32 for recovery time (P < 0.001 for both items). Patients that received labetalol (4 mg/min) had significantly lower amounts of hemorrhage compared to other group (P = 0.001), and the surgeon's satisfaction was significantly higher in the second group (P = 0.001). The frequency of hypotension and bradycardia during the surgery were significantly higher among patients that received labetalol at the dose of 4 mg/min (P = 0.002 and P = 0.001, respectively). The patients in the group labetalol at 4 mg/min had also significantly lower systolic and diastolic blood pressure and lower mean arterial pressure (MAP) compared to the other group (P < 0.05). Conclusions: Administration of labetalol at the dose of 4 mg/min had significantly desirable effects on hemodynamics that resulted in reduced bleeding volume and blood pressures compared to labetalol at the dose of 2 mg/min.

Clinical Applications of Aspirin as a Multi-potent Drug Beyond Cardiovascular Implications: A Proof of Concept for Anesthesiologists- A Narrative Review

To the best of our knowledge, aspirin (ASA) is known as a commonly used medication worldwide. Although the cardiovascular aspects of ASA are well-established, recently, it has been identified that ASA can yield multiple extra-cardiovascular therapeutic potencies in facing neurodegenerative disorders, various cancers, inflammatory responses, and the COVID-19 pandemic. In this review, we aimed to highlight the proven role of ASA administration in the variety of non-cardiovascular diseases, particularly in the field of anesthesiology.

Comparison of Intraoperative Infusion of Remifentanil Versus Fentanyl on Pain Management in Patients Undergoing Spine Surgery: A Double Blinded Randomized Clinical Trial

Background

Remifentanil is an ultra-short-acting opioid which facilitates hemodynamic management. However, there are concerns about postoperative Remifentanil hyperalgesia because of its potent fast onset and offset.

Objectives

The aim of this study was to determine visual analog scale (VAS), postoperative pain, and morphine used in two groups after spine surgery.

Methods

In this randomized clinical trial study, 60 patients aged 18 - 60 years old, according to the American Society of Anesthesiology (ASA) I - II, who underwent spinal canal stenosis or scoliosis surgery, were divided into two groups. In the control group, patients received 0.07 - 0.1 µg/kg/h intraoperative Fentanyl infusion, and in the intervention group 0.1 - 0.2 µg/kg/min remifentanil was infused during the surgery. Both groups received 15 mg/kg intravenous Acetaminophen 20 minutes before the end of the surgery. Postoperative pain score and morphine consumption were measured 6, 12, 24, and 48 hours after discharge from the post-anesthesia care unit (PACU).

Results

During the first 12 hours, VAS and morphine consumption were significantly higher in remifentanil group (P < 0.001). However, no significant difference was found between the two groups in morphine consumption 12 - 48 hours after surgery.

Conclusions

These findings suggest that Remifentanil infusion during surgery may increase postoperative pain. Also, VAS and morphine consumption were higher during the first 12 hours.

Comparison of the Effects of Haloperidol and Dexmedetomidine on Delirium and Agitation in Patients with a Traumatic Brain Injury Admitted to the Intensive Care Unit

Background

Patients under mechanical ventilation in the Intensive Care Unit (ICU) have a higher risk of delirium. To date, the ideal sedative combination for delirium treatment in terms of cost and side effects has not been determined.

Objectives

This study was designed to compare the effects of haloperidol and dexmedetomidine on delirium in trauma patients under mechanical ventilation in the ICU.

Methods

Sixty patients with a moderate traumatic brain injury were randomly divided into two groups. Patients in the haloperidol group received 2.5 mg of haloperidol intravenously every eight hours for ten minutes daily, and the dexmedetomidine group received 0.5 µg/kg of dexmedetomidine via intravenous infusion every other day. Delirium, agitation, length of hospitalization, duration of mechanical ventilation, and need for sedation up to seven days were measured and recorded in both groups. The Richmond Agitation-Sedation scale (RASS) and Acute Physiology and Chronic Health evaluation (APACHE II) scales were used to determine the level of agitation in patients. The Confusion Assessment method (CAM)-ICU criteria were used to determine the incidence of delirium.

Results

Based on the results of this study, age and sex of the two groups were not significantly different. The mean age of the patients was 36.83 years in the haloperidol group and 40.1 years in the dexmedetomidine group. After the intervention, there was no significant difference in terms of the level of consciousness, number of days required for ventilation (P = 0.17), and number of days in the ICU (P = 0.49); however, there was a significant difference between the two groups three to seven days after the intervention. Besides, there was a significant difference between the two groups regarding the incidence of delirium five to seven days after the intervention (P < 0.05).

Conclusions

There was a significant difference between the two groups in terms of the incidence of delirium and the level of agitation; the patients in the dexmedetomidine group were calmer and experienced less delirium.

Effect of Different Loading Doses of Dexmedetomidine on Controlled Hypotension and the Incidence of Bradycardia During Rhinoplasty: A Clinical Trial

Controlled hypotension, with a mean arterial pressure (MAP) of 60 mmHg - 70 mmHg, provides a bloodless and visible surgical field during rhinoplasty. It has been shown that dexmedetomidine, an α2-adrenoreceptor agonist, is a suitable choice in this regard. One of the disadvantages of this drug is the possibility of severe bradycardia during infusion. Therefore, we compared lower intravenous (IV) loading doses to determine whether the hypotensive effect of the drug was preserved and the bradycardia incidence decreased. In this randomized, double-blinded clinical trial, 81 patients aged 18 to 50 years with the American Society of Anesthesiologists physical status (ASA-PS) class I and II, scheduled for rhinoplasty randomly received 1.0, 0.9, and 0.8 µg/kg (named as groups 1.0, 0.9, and 0.8, respectively) of IV dexmedetomidine before the induction of anesthesia followed by infusion (0.3 - 0.7 µg/kg/h) during operation. The patients' heart rate (HR), MAP, the requirements for nitroglycerin (NTG) and extra fentanyl, as well as the incidence of bradycardia, were recorded. Bleeding and visibility of the surgical field were scored by the surgeon using a 6-point visual scale. MAPs, HRs, and consumption of NTG and extra fentanyl were similar in the studied groups. The surgical field was more visible and bloodless in group 1.0 compared to group 0.8 (P < 0.001); the differences were not significant between groups 1.0 and 0.9 (P = 0.605). The incidence (P = 0.027) and the severity of bradycardia (P = 0.017) were higher in the groups with higher loading doses. We concluded that dexmedetomidine is an acceptable agent to provide controlled hypotension. A loading dose of 0.9 µg/kg, but not 0.8 µg/kg, provides similar surgical field conditions as the dose of 1 µg/kg. Furthermore, despite the decrease in the incidence of bradycardia, the hypotensive effect of the drug is preserved.

Opioid-Free Anesthesia Benefit-Risk Balance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Opioid-free anesthesia (OFA) is used in surgery to avoid opioid-related side effects. However, uncertainty exists in the balance between OFA benefits and risks. We searched for randomized controlled trials (RCTs) comparing OFA to opioid-based anesthesia (OBA) in five international databases. The co-primary outcomes were postoperative acute pain and morphine consumption at 2, 24, and 48 h. The secondary outcomes were the incidence of postoperative chronic pain, hemodynamic tolerance, severe adverse effects, opioid-related adverse effects, and specific adverse effects related to substitution drugs. Overall, 33 RCTs including 2209 participants were assessed. At 2 h, the OFA groups had lower pain scores at rest MD (0.75 (−1.18; −0.32)), which did not definitively reach MCID. Less morphine was required in the OFA groups at 2 and 24 h, but with very small reductions: 1.61 mg (−2.69; −0.53) and −1.73 mg (p < 0.05), respectively, both not reaching MCID. The reduction in PONV in the OFA group in the PACU presented an RR of 0.46 (0.38, 0.56) and an RR of 0.34 (0.21; 0.56), respectively. Less sedation and shivering were observed in the OFA groups with an SMD of −0.81 (−1.05; −0.58) and an RR of 0.48 (0.33; 0.70), respectively. Quantitative analysis did not reveal differences between the hemodynamic outcomes, although severe side effects have been identified in the literature. No clinically significant benefits were observed with OFA in terms of pain and opioid use after surgery. A clear benefit of OFA use was observed with respect to a reduction in PONV. However, more data on the safe use of OFAs should be collected and caution should be taken in the development of OFA.

Comparison of the Effect of Dexmedetomidine and Remifentanil on Pain Control After Spinal Surgery: A Double-Blind, Randomized Clinical Trial

Background

A variety of spinal surgery procedures are performed on patients with different cardiac, vascular, and respiratory comorbidities. Postoperative pain management is a major determinant of hemodynamic and respiratory status in these patients and promotes clinical results, prevents complications, saves health services, and improves the quality of life of patients.

Objectives

We compared the effects of dexmedetomidine and remifentanil on pain control after spinal surgery.

Methods

Sixty patients aged 18 - 65 years undergoing spinal surgery were randomized into the two groups of dexmedetomidine and remifentanil. The dexmedetomidine group (group D, n = 30) received dexmedetomidine infusion (0.6 mcg/kg/h), and the remifentanil group (group R, n = 30) received remifentanil infusion (0.1 mcg/kg/min) from induction of anesthesia until extubation. Propofol (1.5 mg/kg) and fentanyl (2mcg/kg) were used to initiate anesthesia, and propofol (100 - 150 mcg/kg/min) was infused to maintain anesthesia. Postoperative pain, hemodynamic parameters, and recovery characteristics were evaluated after surgery.

Results

The mean pain intensity in the dexmedetomidine group was significantly lower than in the remifentanil group (2.98 ± 1.29 vs. 3.80 ± 1.1; P < 0.001). Hemodynamic changes in the dexmedetomidine group (MAP: 92.60 ± 5.56, HR: 73.07 ± 7) were less, and their condition was significantly more stable than in the remifentanil group (MAP: 93.85 ± 4.78, HR: 79.15 ± 7.03; P < 0.05). The mean arterial oxygen saturation (O₂ sat) in the dexmedetomidine group was significantly higher and more stable than in the remifentanil group (98.87 ± 0.51 vs. 97.92 ± 0.46; P < 0.05). The incidence of nausea and vomiting was significantly lower in the dexmedetomidine group compared to the remifentanil group (P < 0.05). The administration of analgesics in the post-anesthetic care unit (PACU) was significantly higher in the remifentanil group than the dexmedetomidine group (P = 0.016).

Conclusions

Anesthetic maintenance with either dexmedetomidine or remifentanil infusion until extubation provided more smooth and hemodynamically stable conditions, without complications. However, dexmedetomidine provides better analgesia, causes a more stable hemodynamic state, and reduces postoperative nausea-vomiting, shivering, and the need for analgesics.

Efficacy of Dexmedetomidine Infusion Without Loading Dose on Hemodynamic Variables and Recovery Time During Craniotomy: A Randomized Double-blinded Controlled Study

Background

Maintaining hemodynamic stability during intracranial surgery is one of the most important tasks. There is no general agreement regarding which anesthetics are optimal for craniotomy. Propofol and short-acting opioids are usually used, but their use is not without side effects. Recently, dexmedetomidine has been considered a safe alternative in different surgeries.

Objectives

We aimed to assess the efficacy of 0.5 µg/kg/h dexmedetomidine infusion without loading dose as an adjunct to general anesthesia for craniotomy.

Methods

A prospective, randomized, double-blinded, parallel-group, placebo-controlled trial was conducted. Setting: Single university teaching hospital’s operating rooms and postoperative intensive care unit. Patients: A total of 50 patients scheduled for elective supratentorial craniotomy participated in this study. Interventions: Patients were randomly divided into either control group (group C) and Dexmedetomidine group (group D). Main outcome measure: Intraoperative hemodynamics measurements at specific timings.

Results

We found that dexmedetomidine had significantly maintained mean arterial blood pressure and heart rate (P-value < 0.001); with lower intraoperative fentanyl and propofol consumption in group D (132 ± 35 µg and 14 ± 30 mg, respectively) when compared to group C (260 ± 38 µg and 534 ± 66 mg, respectively). Finally, a lesser sedation level was noticed in the dexmedetomidine group, together with a significantly lesser recovery time of 10.3 ± 4 min.

Conclusions

Dexmedetomidine infusion without loading dose could be an efficacious and safe agent in achieving hemodynamic stability with intraoperative opioid-sparing effect and lesser recovery time.

To Compare the Efficacy of Dexmedetomidine Versus Labetalol in Providing Controlled Hypotension in Functional Endoscopic Sinus Surgery

Background

Functional endoscopic sinus surgery (FESS) is a surgical intervention for sinus diseases. Bleeding is a common concern during FESS. Hemodynamic stability and quality surgical field visibility help to achieve the best outcomes.

Objectives

The present study primarily intended to compare the effectiveness of dexmedetomidine versus labetalol in providing controlled hypotension during FESS and then to assess the quality of the surgical field.

Methods

The current research was conducted as a prospective randomized double-blinded clinical study. Sixty patients of the American Society of Anesthesiologists grade I or II status undergoing FESS under general anesthesia were divided into two groups, each with 30 members. Patients receiving dexmedetomidine and labetalol were named as group D and L, respectively. The study intended to manage mean arterial pressure (MAP) between 65 - 75 mmHg. The visibility of the operative field was evaluated using Fromme and Boezaart scoring system. Total intraoperative fentanyl consumption and postoperative first analgesic request time were recorded.

Results

The MAP target was achieved in both groups. Intergroup differences concerning MAP were observed in both D (75.0 ± 2.0) and L (82.4 ± 5.2) groups (P-value < 0.05). Scores for blood loss were significantly lower in the D group (1.3 ± 0.3) compared to the L group (2.1 ± 0.3) (P-value < 0.05). There was no intergroup difference concerning the mean heart rate (group D; 70.8 ± 4.2, and group L; 73.4 ± 4.4). The total dose of fentanyl consumed was found to be significantly lower in the group D (41.9 ± 5.8) compared to group L (59.9 ± 5.3) (P-value < 0.05). The first analgesic request time was significantly longer in the group D (50.2 ± 9.1) compared to group L (24.8 ± 5.1) (P-value < 0.05).

Conclusions

Dexmedetomidine provided better hemodynamic stability and operative field visibility as compared to labetalol during FESS.

The Effect of Low-Dose Atorvastatin on Inflammatory Factors in Patients with Traumatic Brain Injury: A Randomized Clinical Trial

Background: Traumatic brain injury (TBI) is the leading cause of morbidity and mortality. Each year near 1.5 million Americans experience a TBI. Of which about 235,000 are hospitalized. Also, TBI claims 50 000 American lives each year. TBI causes mechanical damage to the blood-brain barrier and white blood cells (WBCs) entry to the brain. Objectives: The current study aimed to evaluate the efficacy of low-dose Atorvastatin on inflammatory factors in patients with traumatic brain injury (TBI). Methods: This double-blind, randomized clinical trial study was conducted in the ICU ward of Golestan Hospital in the city of Ahvaz (Iran) from April 2019-May 2020. Sixty patients with moderate to severe TBI were studied. Patients were randomly assigned into two groups of Atorvastatin and control. The main outcomes included the amount of CRP and ESR as well as white blood cells in the first 14 days of hospitalization. Glasgow Coma Score, the length of ICU stay, and the duration of mechanical ventilation were secondary outcomes. Results: The amount of CRP in the Atorvastatin group on the 14th day of hospitalization was significantly lower than those in the control group (31.99 ± 8.38 vs 59.65 ± 10.43) (P < 0.0001). On the same day, the Atorvastatin group had lower levels of ESR than the control group (14.28 ± 4.18 vs 25.57 ± 5.18) (P < 0.0001). The Atorvastatin group had significantly lower levels of white blood cells than the control group (5247.53 ± 751.93 vs 7143.94 ± 907.64, P < 0.0001). Glasgow Coma Score at the time of discharge from the ICU in the Atorvastatin group was more than control (14.06 ± 1.45 and 11.85 ± 0.75, respectively) (P < 0.05). A significant difference was found concerning the ICU stay between the two groups (P = 0.03). Conclusions: This study demonstrated that Atorvastatin could reduce the rate of inflammatory factors in TBI patients. The inflammatory condition of TBI patients heavily determines their prognosis. Inflammation leads to several reactions as well as interactions between different cells and chemical mediators. The Atorvastatin could reduce the rate of inflammatory factors and improved GCS in TBI patients.

The role of exogenous Fibrinogen in cardiac surgery: stop bleeding or induce cardiovascular disease

The surgical treatment contributes to broad variety of cardiovascular diseases (CVD). Due to many involved factors in preoperative bleeding, it is almost difficult to perform better Haemostatic approach. Fibrinogen is a major blood glycoprotein and a coagulation factor which decreases postoperative bleeding. It has a potential role in platelet activation and bleeding inhibition; it may reflect the inflammatory responses and be related to the endothelial dysfunction. Fibrinogen can act as a pro-inflammatory element via increasing some inflammatory markers including IL-6, tumor necrosis factor-α (TNF-α), monocyte chemo attractant protein (MCP-1), macrophage inflammatory protein-1 (MIP-1a and b), matrix metalloproteinase (MMP-1 and MMP-9) and Toll-like Receptors (TLRs); through activation of these factors, fibrinogen may induce some inflammatory mechanisms such as focal adhesion kinase (FAK), mitogen-activated protein kinases (MAPK) and nuclear factor κB (NF-κB) pathways. It may cause endothelial dysfunction by increasing P and E-selection, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) levels which activate MAPK and NF-κB pathways. This factor is also associated with increased exocytosed von Willebrand factor (vWF) as well as activation of Rho-GTPase mechanism. All of these data demonstrate the dual role of fibrinogen in cardiac surgeries, bleeding inhibition and CVD. Therefore, identifying the CVD factors is helpful for designing preventive strategies and alternative drugs.

The potential similarities of COVID-19 and autoimmune disease pathogenesis and therapeutic options: new insights approach

Abstract

Cytokine pathways and their signaling disorders can be the cause of onset and pathogenesis of many diseases such as autoimmune diseases and COVID-19 infection. Autoimmune patients may be at higher risk of developing infection due to the impaired immune responses, the use of immunosuppressive drugs, and damage to various organs. Increased secretion of inflammatory cytokines and intolerance of the patient’s immune system to COVID-19 infection are the leading causes of hospitalization of these patients. The content used in this paper has been taken from English language articles (2005–2020) retrieved from the PubMed database and Google Scholar search engine using “COVID-19,” “Autoimmune disease,” “Therapeutic,” “Pathogenesis,” and “Pathway” keywords. The emergence of COVID-19 and its association with autoimmune disorders is a major challenge in the management of these diseases. The results showed that the use of corticosteroids in the treatment of autoimmune diseases can make diagnosis and treatment of COVID-19 more challenging by preventing the fever. Due to the common pathogenesis of COVID-19 and autoimmune diseases, the use of autoimmune drugs as a possible treatment option could help control the virus.

Key Points

• Inflammatory cytokines play an essential role in the pathogenesis of COVID-19

• ACE2 dysfunctions are related to the with COVID-19 and autoimmune diseases

• The use autoimmune diseases drugs can be useful in treating COVID-19

Comparison of Sedation with Dexmedetomidine Alfentanil Versus Ketamine-Alfentanil in Patients Undergoing Closed Reduction of Nasal Fractures

Objectives

To compare the sedative effects of dexmedetomidine alfentanil versus ketamine-alfentanil in patients undergoing closed reduction of nasal fractures on the basis of intraoperative hemodynamic changes, satisfaction of patients and surgeons, and the adverse effects.

Methods

Sixty patients with ASA class 1 or 2 were randomized to either of two groups, a dexmedetomidine alfentanil group (DA group; n = 30) or a ketamine-alfentanil group (KA group; n = 30). Hemodynamic parameters, oxygenation status, adverse events, the satisfaction of patients and surgeons, and postoperative pain scores by visual analog scale (VAS) were recorded at specific time intervals during the trial.

Results

Systolic blood pressure was significantly lower in the DA group than in the KA group from T1 min to T15 min. The duration of the recovery ward stay was longer in the DA group; however, two groups were similar in terms of total anesthesia time and awakening time. Likewise, two groups were similar in terms of the patient and surgeon’s satisfaction, pain scores, and the occurrence of adverse effects.

Conclusions

Both sedation methods were safely performed, and dexmedetomidine-alfentanil is as effective as ketamine-alfentanil in patients undergoing short-term operations such as nasal fracture corrections.

The effect of melatonin on reduction in the need for sedative agents and duration of mechanical ventilation in traumatic intracranial hemorrhage patients: a randomized controlled trial

Purpose

This study aimed to determine the effect of exogenous melatonin on the number of sedative drugs and the duration of mechanical ventilation in traumatic intracranial hemorrhage patients in ICU.

Methods

This double-blind randomized clinical trial study was conducted in the ICU wards of Golestan Hospital, Ahvaz, Iran, from September 2017 to March 2018. In this study, 52 patients with intracerebral hemorrhage were selected by convenient sampling (26 patients in each group) and were randomly assigned to two groups of melatonin and control. Sedation and pain management package was applied to both groups. Outcomes: Amount of the sedative and opioid drug; mechanical ventilation time; ICU staying time; Glasgow Coma Score; hemodynamic parameters.

Results

There was no significant difference between them in terms of demographic characteristics. Cumulative doses of morphine and mechanical ventilation time were significant in two groups. (P < 0.05) The mean length of ICU staying was not significant. Glasgow Coma Score on the 6th day was significant in two groups (P < 0.05). Diastolic blood pressure was significant between groups (P < 0.001).

Conclusion

This study presented that morphine consumption and mechanical ventilation time were significantly lower in the melatonin group than in the control. Also, rise in GCS in the melatonin group was faster in the melatonin group than in the control. The use of melatonin can be recommended for patients with ICH in the ICU for better outcomes.

Dexmedetomidine Compared to Remifentanil Infusion as Adjuvant to Sevoflurane Anesthesia during Laparoscopic Sleeve Gastrectomy

Objectives

Evaluation of postoperative (PO) analgesic effects of intraoperative (IO) Dexmedetomidine (DEX) compared to remifentanil (REMI) infusions during sevoflurane anesthesia for laparoscopic gastric sleeve surgery.

Patients and Methods

One hundred and thirty-two patients with body mass index >35 kg.m^-2 and ASA Grades II or III were randomly divided into group R received REMI infusion (6-18 μg.kg^-1.h^-1) and Group D received DEX infusion (0.2-0.5 μg.kg^-1.h^-1) after tracheal intubation till before stoppage of inhalational anesthetic. Heart rate and mean arterial pressure were noninvasively monitored during and after surgery. Emergence time, time until postanesthetic care unit transfer, and total operating room (OR) time was recorded. PO shoulder-tip pain and wound pain scores were recorded and rescue analgesia was provided as 50 mg pethidine intramuscular injection. Occurrence of PO nausea and vomiting (PONV) and frequency of the need for antiemetic therapy were recorded. Primary study outcome was the ability of the study infusions to reduce consumption of PO pethidine down to one dose during 24-hr PO.

Results

IO use of REMI or DEX infusion allowed hemodynamic control to surgical stresses with nonsignificant difference between both infusions. REMI infusion insured significantly rapid recovery and short OR times but required larger volume of sevoflurane during surgery and proper PO follow-up for pain and PONV. DEX infusion significantly improved control of PO pain with a larger number of patient requested rescue analgesia only once, reduced the dose of PO analgesia, reduced the frequency of PONV, and the need for antiemetic therapy.

Conclusion

REMI or DEX infusion as IO adjuvant to general anesthesia is appropriate option to achieve hemodynamic control of surgical stresses and to improve perioperative outcomes. REMI infusion may be preferred for its induced rapid recovery and short OR time, whereas DEX infusion may be chosen for its improved control of PO pain and reduction of PO analgesia and frequency of PONV.

Remifentanil inhibits the traumatic stress response in emergent trauma surgery

OBJECTIVE

The aim of this study was to explore whether remifentanil could inhibit the stress response in emergent trauma surgery more effectively than sufentanil.

PATIENTS AND METHODS

Sixty trauma patients for emergent surgery were randomly divided into remifentanil group (R group, n = 30) or sufentanil group (S group, n = 30). The patients in the R group were continuously intravenously infused with remifentanil, while those in the S group were administrated with sufentanil. The plasma contents of cortisol (COR), epinephrine (E), norepinephrine (NE), and blood glucose were measured before anesthesia induction (T1), 5 minutes after intratracheal intubation (T2) and 5 minutes (T3), 30 minutes (T4), and 1 hour (T5) after surgery, respectively. The blood pressure (BP) and the heart rate (HR) at these time points were recorded as well.

RESULTS

The results showed that the patients in the R group had more stable hemodynamics during the surgery and had a significantly lower HR at T2-T5 than those in the S group. The plasma levels of norepinephrine at time points T3-T5 and levels of cortisol at T4-T5 in the R group were significantly lower than those in the S group (P < 0.05).

CONCLUSIONS

The results in the present study indicated that remifentanil could inhibit the stress response in emergent trauma surgery patients more effectively than sufentanil.

The Effect of Fibrinogen on Blood Loss After Lumbar Surgery: A Double-Blind Randomized Clinical Trial

Background

Spinal surgeries often have a high risk of hemorrhage during and after surgery, thus most patients require blood transfusions and blood products. Fibrinogen is used in different forms to control hemorrhage.

Objectives

The present study aimed to evaluate the outcomes of prophylactic fibrinogen administration in reducing hemorrhage after lumbar surgery.

Methods

This was a randomized clinical trial conducted on 30 patients undergoing lumbar surgery. The levels of fibrinogen, as well as hemoglobin (HB), hematocrit (HCT), prothrombin time (PT), partial thromboplastin time (PTT), and INR, were assessed preoperatively as the baseline values. The patients were divided into two groups: intervention (N = 15) and control (N = 15) groups. The intervention group received 1 g fibrinogen dissolved in 50 cc distilled water with surgical incision and the control group received 50 cc distilled water with the surgical incision. At the end of the operation, the volume of hemorrhage transfused blood products (fresh frozen plasma, packed cell, and platelet) was measured. In addition, at 0, 6, and 24 hours after the end of surgery and transfer to recovery, serum levels of fibrinogen, HB, HCT, INR, PT, PTT, and hemovac drain volume were measured.

Results

The hemorrhage during and after the operation in the control group was significantly higher than that of the intervention group (P < 0.05). There were no significant differences between hemoglobin and serum level of fibrinogen before and after surgery between the two groups. The postoperative hypotension showed no significant difference between the two groups.

Conclusions

The findings showed the effectiveness of fibrinogen in reducing acute hemorrhage. Considering the adverse consequences of hemorrhage and coagulopathy in patients undergoing surgery, using fibrinogen as prophylaxis is recommended in surgeries with high risks of hemorrhage.

Comparing the Effect of Clonidine and Dexmedetomidine on Intraoperative Bleeding in Spine Surgery

Background

Discopathy is one of the most common spinal surgeries. Hemodynamic control is important in bleeding reduction during the surgery. Clonidine and dexmedetomidine both are α² agonists that help stabilize hemodynamics and prevent the increase of intraoperative bleeding.

Objectives

In this study, the effects of clonidine and dexmedetomidine were compared in bleeding reduction during spinal surgery.

Methods

This randomized, double-blind clinical trial was conducted in 120 patients aged 20 to 50 years with ASA class I or II, undergoing spinal surgery. Patients were randomly divided into three groups. Group C received oral clonidine 0.2 mg, 90 minutes before entering the room. Group D received dexmedetomidine 0.5 µ/kg 15 minutes before anesthesia induction and 0.25 µ/kg/h infusion during operation. Group P received placebo as the control group.

Results

There was a significant reduction in intraoperative blood loss in patients who received clonidine (289 ± 130) and dexmedetomidine (344 ± 145) compared to the control group (462 ± 15) (P < 0.05), with a more dramatic reduction in the clonidine group (P < 0. 001).